Originally published at Pediatric EM Morsels on November 28, 2014. Reposted with permission.

Follow Dr. Sean M. Fox on twitter @PedEMMorsels

Every so often you encounter a patient that has a finding that catches you by surprise.  Like having air in places that should not have air in them.  We have discussed spontaneous pneumothorax and traumatic pneumothorax in children as well as how to detect pneumothorax in neonates and how to treat a pneumothorax, but what about pneumomediastinum?  As you try to resist the urge to say “D’Oh!” let us consider Pneumomediastinum!


Pneumomediastinum Basics

  • Symptoms
    • Pain – Chest Pain, Neck Pain, Throat Pain
    • Hoarseness, Stridor, Cough
    • Globus Pharyngeus – persistent or intermittent, non-painful sensation of swelling or foreign body in throat.
    • Dyspnea, Choking
    • Facial and/or Neck Swelling
  • Imaging Modality
    • Lateral Neck Soft Tissue plain film is more sensitive than PA CXR (95.2% vs 89.1%). (Wang, 2013)
    • CT is certainly more sensitive than plain radiographs, but would not be a reasonable screening strategy.


Pneumomediastinum Causes

  • Primary Pneumomediastinum = presence of air within the mediastinum with NO obvious precipitating event.
    • Of cases of pneumomediastinum one study found ~50% were Spontaneous Primary Pneumomediastinum. (Wong, 2013)
  • Secondary Pneumomediastinum = Pneumomediastinum is present due to a defined etiology:
    • Spontaneous (Wong, 2013)
      • Asthma Exacerbation – ~17%
      • Pneumonia or Lower Respiratory Tract Infection – ~13%
      • Choking Events / Foreign Body Aspiration – ~12%
      • Viral Illness / Cough / Croup – ~3%
      • Spontaneous esophageal or bronchial rupture are very rare causes of pneumomediastinum in kids.
    • Traumatic (Pryor, 2011)
      • Relatively uncommon after trauma to neck, thorax, or abdomen.
      • Can be associated with life-threatening tracheobronchial, esophageal, or vascular injuries.
        • All of the patients who had significant injury to trachea/bronchus, esophagus, or vascular structures were identified on CXR.
        • Most common associated injuries found with complicated pneumomediastinum were:
        • Less common to see significant mediastinal injuries in children than adults.


Age Matters with Pneumomediastinum

  • In children less than 6 years of age, spontaneous primary pneumomediastinum is very rare. (Wang, 2013)
    • For young kids, look more diligently for a cause of the pneumomediastinum.
    • Asthma exacerbation is a common cause.
    • Keep Foreign Bodies on the DDx as they can be tricky. (Hu, 2012)
      • With a history of choking / gagging, have a low threshold to obtain bronchoscopy / esophagoscopy.
  • Children older than 6 can have spontaneous primary pneumomedisastinum.
    • Base evaluation of it on the history and presentation.


Advanced Investigations??

  • Naturally, the question is what needs to be done once you have diagnosed the pneumomediastinum.
  • When do you need to look for potential causes of Secondary Pneumomediastinum?
  • Here is a proposed strategy (Wang, 2013):
    • Manage conservatively if:
      • Presents with an asthma exacerbation,
      • Presents with recent onset of fever,
      • Presents with vigorous cough,
      • Presents with NO choking episodes.
    • Consider further investigations as indicated (ex, bronchoscopy, esophagoscopy, Upper GI/Swallow study, Chest CT) if:
      • Presents after a catastrophic event,
      • Presents after a choking episode,
      • Presents with dysfunctional swallowing,
      • Presents after trauma and has clinical evidence of aerodigestive injury. (Neal, 2009)
    • Consider Age
      • Have lower threshold for further evaluation in the younger child (as they are less likely to have spontaneous primary pneumomediastinum.
      • Extensive diagnostic evaluations in uncomplicated spontaneous pneumomediastinum in adolescents is often unnecessary.
    • Consider Clinical Course
      • Kids with isolated pneumomediastinum, no other abnormalities on CXR, and low risk mechanism (if traumatic) are at at low risk for tracheobronchial, esophageal, or vascular injuries, so observation alone would be appropriate; however, if clinically worsens, than reconsider other potential problems. (Pryor, 2011)
      • Not all that wheezes is asthma… Foreign Bodies can be difficult to diagnose, so reconsider this potential if patient does not respond to therapy as you’d expect.


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‘My Mental Toughness Manifesto’ Part 4: PROCESS


Everything in aviation we know because someone somewhere died… We have purchased, at great cost, lessons literally bought with blood… We cannot have the moral failure of forgetting these lessons and have to relearn them.”

Sully Sullenberger
Pilot of Flight 1549, ‘The Miracle on the Hudson’

All frontline healthcare warriors will bear scars from emotionally distressing experiences in the workplace (e.g. major incidents with multiple casualties, unsuccessful paediatric resuscitations, personal mistakes resulting in patient harm). For the most part, members of the public will only rehearse being exposed to these flavours of horror by watching movies or having nightmares. For us, it is a potential reality every shift.

In the aftermath, the way one processes these events heavily influences future commitment to similar causes and cognitive appraisals (challenge vs threat mindset) – the key determinants of mental toughness.

Adaptive processing should incorporate ‘Black Box Thinking’ and self-compassion. 

‘Black Box Thinking’

BBT betterConsider the aviation vs healthcare discussion for a moment – arguably the two most safety-critical industries in the world.

On average, just one commercial flight goes down for every 8.3 million take-offs worldwide. In the US alone, there are approximately 400, 000 avoidable medical errors every year, which is the equivalent of two jumbo jet crashes every day [1, 2]. That is a gargantuan discrepancy in passenger versus patient safety.

Of course, it is well documented that the two industries are not directly comparable. There are far more reasons for a patient to die than there are varieties of plane crash, and medics do not yet have the option to switch on a mental bandwidth-sparing machine that’s able to mop up routine tasks. Nonetheless, the statistics illustrate an indisputable point – we have a huge amount to learn from our aviation counterparts, whether we like it or not.

Why is aviation such a staggeringly high performance industry? The answer is simple: there is an institutional culture of learning from failure. Every plane is equipped with two sturdy black boxes which record conversation in the cockpit, and electronic decision-making (i.e. which buttons were pushed). In the case of an accident, the black boxes are promptly retrieved from the battered fuselage, opened, and the contained data interrogated. Every aspect of the crash gets the fine-tooth-comb-treatment to identify exactly what went wrong. Protocols are subsequently modified so the same mistake can never happen again. Error is not viewed as a sign of weakness or inadequacy – on the contrary, it is treated as a precious (even exciting) learning opportunity for everyone who might benefit.

Healthcare culture is largely the polar-opposite. Failure is stigmatised because doctors are supposed to be infallible in the eyes of the public. Mistakes get ‘swept under the carpet’ by the guilty to avoid being held accountable and where that is not possible, the blame-game ensues [3]. When one’s professional credibility is at stake, a successful escape from the situation is higher up the priority list than learning from the failure; and the omnipresent threat of litigation only serves to further entrench this defensive, maladaptive institutional culture. The immediate gratification of reputation-preservation trumps the potential for professional growth that naturally follows acknowledgement of personal failure. We routinely blind ourselves to the best possible signposting for getting better at our jobs – our mistakes.

Whilst this growth-stunting phenomenon will vary in severity across the spectrum of healthcare environments, you would be hardpressed to find a doctor, anywhere in the world, not regularly exposed to this embarrassing peculiarity of our profession.

Be a black box thinker. Own your mistakes. Share your lessons. Interrogate every performance with the curiosity and tenacity of the Air Accidents Investigation Branch. Re-conceptualise your relationship with failure so that it no longer represents an existential threat, but acts as a guide for your ‘practice’ phase.

‘Reflective practice’ is an overused and misunderstood term in medical training (in my opinion). Often, written evidence of it is a requirement for career progression, and when one ‘reflects’ for that reason alone, it ceases to be useful. Furthermore, documented reflections will too frequently centre around what went well – a less lucrative training exercise.

Apply the black box philosophy to your reflective practice and force yourself to face potentially ugly truths. Embrace being criticised and never back down from asking a ‘stupid question’ – it tees you up for focused training and subsequent accelerated improvement. Have the bravery to be the detective leading the warts-and-all investigation on yourself.


In frontline healthcare, we are routinely exposed to life-changing injury and acute illness. If we take our workplace goggles off, and dare to view the worst aspects of our jobs through the eyes of a ‘normal’ person, it can be intensely disturbing. Furthermore, subscribing to the highest professional standards can make us prone to gratuitous suffering as we’ll mistakenly convince ourselves that we could have done more for unsalvageable patients. Our keenness to take full responsibility can render us vulnerable to unnecessary self-punishment.

Without appropriate perspective and personal support, our view of the world, and indeed of ourselves, can become warped. Long-term self-neglect in our line of work will eat away at our commitment to the job, potentially invite long-term psychological damage (PTSD), and ultimately, harm our patients.

When a particularly traumatising incident occurs, many institutions will employ a ‘critical incident stress management’ (CISM) protocol, which encompasses a range of supportive interventions aimed at preventing PTSD [4]. This includes a formal group debrief, led by an outside party (usually a psychologist) within 72 hours of the event. Despite being widely practiced, this approach is controversial as no definitive benefit has been demonstrated in the literature. However, widely accepted to be of critical importance for psychological wellbeing in the immediate aftermath of an emotionally traumatising incident is a ‘defusion’ process [4, 5, 6].

‘Defusion’ is a team get-together where thoughts and feelings are shared in confidence. When threat appraisals drench our brains in cortisol and distort our perceptions, defusion allows for piecing together the chronology and specifics of the event through organic, informal discussion with team-mates. It is an opportunity for emotional support, having a collective laugh/cry at the absurdity of the job, and an accurate information gathering exercise in a safe environment. The team pull together in the aftermath, are honest about their emotional frailties, and find strength in each other. It lacks the rigidity and intrusion of an uninvited formal debrief led by an ‘outsider’.

Pain shared = pain divided

Joy shared = joy multiplied [7]

In the hospital setting, it can be as simple as insisting on a chat in the coffee room after a big resus, or a quick get-together after work. It might seem minor, but unnecessary guilt, anger, confusion and other damaging emotions can be thwarted by this process. However informal and insignificant it might appear on the surface, it is of fundamental importance, and must be sought out, however logistically difficult.

In more extreme environments, such as combat or the prehospital setting, sitting down to defuse should also be used as an opportunity to regain a feeling of physical safety, get warm, hydrate and refuel (eat something).

Self-compassion via defusion is a critical strategy for building mental toughness. Taking care of yourself and your team after an acute insult preserves commitment to the job, and prevents lasting psychological scars that will render you less able to cope emotionally with the inevitable acute stress that lies in wait.


Use mistakes as signposts for self-advancement as opposed to sources of embarrassment. Own your failures instead of hiding them, and use them to guide your ‘practice’ phase.

Always remember to ‘defuse’ with your team after emotionally challenging cases/incidents. Share the pain, and multiply the joy. Never underestimate the therapeutic value, and heavy dose of perspective, that humour offers.

‘My Mental Toughness Manifesto’ Roundup

You are mentally tough if able to state the following (Part 1):

“I am 100% committed”

“I feel challenged”

To build and maintain mental toughness, I propose seven strategies over three phases of the game:

‘Practice’ (Part 2)

  • Immersion
  • Deliberate Practice
  • Visualisation

‘Perform’ (Part 3)

  • Tactical Breathing
  • Cognitive Reframing

‘Process’ (Part 4)

  • ‘Black Box Thinking’
  • Self-compassion

Own your performance.

Robert Lloyd


  1. Black Box Thinking. Matthew Syed.
  2. 2017 Royal Society of Medicine Easter Lecture: Creating a high performance revolution in healthcare. Matthew Syed.
  3. What do Emergency Medicine and Donald. J Trump have in common? Robert Lloyd, EMJ Blog.
  4. Mental health response to disasters and other critical incidents. BMJ Best Practice.
  5. Debriefing and Defusing.
  6. Shoes, Sex and Secrets: Stress in EMS. Ashley Liebig. SMACC Chicago lecture.
  7. Grossman, L.C.D., On Combat: The Psychology and Physiology of Deadly Conflict in War and in Peace. 2008: Warrior Science Publications.

The post ‘My Mental Toughness Manifesto’ Part 4: PROCESS appeared first on Pondering EM.

VA ICU Report 5.26.17

Morning, some good neuro critical care action at the VA this week, thought we’d cover something today not yet covered on the blog: non-invasive estimations of elevated ICP, namely fundoscopy and ocular ultrasound

Dan Reiss correctly pointed out the acute finding in elevated ICP on an ocular ultrasound is the optic nerve sheath diameter, a handful of smaller studies (n in each about 40-60) have evaluated the correlation between nerve sheath diameter and MRI/CT findings of elevated CT, Sensitivity and Specificy depends on the cutoff chosen, in adults typically a ONSD of >4.5mm is considered too high, which yields a sens and spec of around 70-80% for the detection of elevated ICP. The challenge here, as with fundoscopy, is inter-observer variability presumably due to operator characteristics. Here is a review paper on non-invasive determination of ICP.

Other quick pearls

#generally opt for beta blockers and ccb in the acute treatment of hypertensive emergency due to the theoretical concern for cerebral vasodilation with nitro/hydral, nicardipine and esmolol are good options

#PRES, covered elswhere, stands for posterior reversible encephalopathy syndrome, though not always posterior or reversible. Remember, MRI is the diagnostic test for PRES.


Filed under: Morning Report, Neurology, Pulmonary and Critical Care Medicine